Sample Type / Medical Specialty: NeurosurgerySample Name: Neuroplasty

Description: Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.
(Medical Transcription Sample Report)PREOPERATIVE DIAGNOSES:1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.2. Epidural fibrosis with nerve root entrapment.

POSTOPERATIVE DIAGNOSES:1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.2. Epidural fibrosis with nerve root entrapment.

OPERATION PERFORMED: Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

ANESTHESIA: Local/IV sedation.

COMPLICATIONS: None.

SUMMARY: The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

NOTE: These
transcribed medical transcription sample reports and examples are provided by various users and
are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.
These transcribed medical transcription sample reports may include some uncommon or unusual formats;
this would be due to the preference of the dictating physician. All names and dates have been
changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or
place or anything else to real world is purely incidental.